depends on account specifics, whether verbatim, etc.
Posted By: nm on 2005-09-07
In Reply to: The patient looks fairly good (or well)? - Becky
Subject: depends on account specifics, whether verbatim, etc.
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It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accou
Subject: It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accounts
with no BOS wanted per the client, regular accounts who do use BOS and others that do not want it, and others that "just type what I say." So, like I said, refer to your account specifics.
Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Subject: Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Depends on account specifics. sm
Subject: Depends on account specifics. sm
In general, we are to write out the term in full the first time it is dictated for clarification. Then, if abbreviations are dictated later on, it is okay to use the abbreviation. Again, you must abide by account specifics. Ask your QA person to be sure.
same here - depends on my account specifics nm
Subject: same here - depends on my account specifics nm
Almost depends on account specifics
Subject: Almost depends on account specifics
Some of the verbatim accounts allow for medical jargon, so if in the body of the report they said he was given 2 amps of bicarb, I would probably just leave it at amps. If this was in a medication list, as on admission or discharge, I would probably write it out as ampule(s).
depends on account specifics, but I usually type 3-1/2 months NM
Subject: depends on account specifics, but I usually type 3-1/2 months NM
Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.
Subject: Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
hardcore verbatim you have to leave it as is, whether it looks ugly or not. I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.
Depends on whether the account is verbatim sm
Subject: Depends on whether the account is verbatim sm
Or how much they expect you to correct. I used to transcribe for a doctor who did the worst run-on sentences and sometimes I would rack my brains trying to figure out where to put punctuation without changing what she said (the account was verbatim except for obvious grammatical errors like subject-verb agreement). Finally I decided, if that's the way she wants to say it, that's what she is going to get. I just made sure that what she was saying made some reasonable kind of sense. She was also notorious for changing her mind half a dozen times in a single sentence, and for not reading her reports before approving them. She once dictated a hysterosalpingogram (test to see if the fallopian tubes are blocked) and let the following impression go out to the requesting physician:
IMPRESSION: Bilateral tubal pregnancy.
instead of
IMPRESSION: Bilateral tubal patency.
(No, I didn't type it!)
Depends if it is a verbatim account. You can do it the way you have it or if he actually used the wo
Subject: Depends if it is a verbatim account. You can do it the way you have it or if he actually used the word "as" 93 then it could be 100-7 as 93 or just minus equal signs. Depends on your client.
depends on whether your account is verbatim (sm)
Subject: depends on whether your account is verbatim (sm)
It's slangy, but depending on the account, I might or might not edit.
Depends on whether the account requires verbatim sm
Subject: Depends on whether the account requires verbatim sm
If they don't, I would change the tense to whatever is the norm for that account or that doctor.
If they do require verbatim, I would type it verbatim but let the QA preson know that the doctor had shifted tenses.
But that's just me....
I use tib-fib, but I would say it depends on the account. Some verbatim accounts do not like abbrevi
Subject: I use tib-fib, but I would say it depends on the account. Some verbatim accounts do not like abbreviations, others want it strictly verbatim. The rest seems appropriate to me, but I would say it is dorsiflex the ankle.
account specifics for that particular account should state how it is to be typed. nm
Subject: account specifics for that particular account should state how it is to be typed. nm
.
Also, don't know about your account specifics but
Subject: Also, don't know about your account specifics but
I would use 1.5 cm, as in 1.5-cm "hypoechoic" mass...decimals for metric...
Account specifics - if they want 's that's what they get. SM
Subject: Account specifics - if they want 's that's what they get. SM
That's what is in AAMT BOS - Depends on client preference, so, no, she is not wrong
All according to your account specifics. Like
Subject: All according to your account specifics. Like
I said below, we do not use slang, therefore use saturating; however if verbatim, then satting is correct.
What do your account specifics say? nm
Subject: What do your account specifics say? nm
nm
Account specifics would dictate whether you sm
Subject: Account specifics would dictate whether you sm
write it out or abbreviate. The abbreviation for beats per minute is bpm. Ask your QA person for approved abbreviations for this account (accounts will differ sometimes which can make us crazy).
do you have account specifics to read?
Subject: do you have account specifics to read?
on most accounts it is acceptable to leave 1-2 blanks. If you really think it sounds like minute, then put that.
also I should have said check your account specifics - SM
Subject: also I should have said check your account specifics - SM
Each doc and/or hospital may want classes and grades a certain way. It is a good idea to make sticky notes like Another KSMT said.
I would check your account specifics...(nm)
Subject: I would check your account specifics...(nm)
First, see your account specifics or client preferences.
Subject: First, see your account specifics or client preferences.
If no mention is made about it, I would type it as a numeral for anything less than 10.
Although I would double check your account specifics. SM.
Subject: Although I would double check your account specifics. SM.
Some docs might prefer you to spell it out for them or have an specific way they want it typed.
check your company's Account Specifics, if you can
Subject: check your company's Account Specifics, if you can
nm
That's what I mean by "ask your QA!" Account specifics dictate style, sm
Subject: That's what I mean by "ask your QA!" Account specifics dictate style, sm
but the AAMT BOS dictates what is correct for the industry, getting its information from sources such as the Chicago Manual of Style, the American Medical Association book of style (which I own), etc. As the poster below states, Joint Commission goes by BOS and does not like "same" or abbreviations for diagnoses, impressions, op titles, etc. They will randomly choose patient charts and go through them to check things like this! It's the Joint Commission which recommends or removes hospital accreditations--a very powerful entity.
So, ask your QA what the account wants. If they want "same," give them "same." For other accounts, do it the correct way.
Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)
Subject: Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)
X
Both are correct, just type it according to your account specifics, some like disc and other disk.
Subject: Both are correct, just type it according to your account specifics, some like disc and other disk.
depends if verbatim sm
Subject: depends if verbatim sm
I personally do not have strict verbatim accounts, so I would not put in the word systolic. Since the doctor is putting in a range (110-120), he wants to make sure you know this is systolic. I doubt it needs to be included.
Depends on your account. nm
Subject: Depends on your account. nm
nm
Depends on account
Subject: Depends on account
My previous company had us leave the names out unless they were pertinent to the patient's care such as a caretaker. I.e. Dictated: Patient's wife, Susan, stated that. Transcribed: Patient's wife stated that. I would ask your QA about that to be sure though.
yes, depends on account
Subject: yes, depends on account
don't just go with the dictator-client may not be happy about it and you'll get in trouble. ask supervisor
It depends on account....sm
Subject: It depends on account....sm
I have been specializing in OPs for several years, (done everything else!), and love it, but we have doctors (have a few hospitals), who will give related system diagnoses and went them in one paragraph form with commas, as you wrote. But then, I have others that specify everything numbered. According the BOS from long ago, in Ops when listing diffent diagnoses, number them, but our rule from our company (owned by an MD!) is that, if they dictate in paragraph form, write it so, and if they dictate "numbered diagnoses," then put in numbered list fashion. Does that make any sense to you? Do you have account specifics for this doctor?? 
depends on whether or not it's a verbatim acct
Subject: depends on whether or not it's a verbatim acct
Honestly, it depends on your account....
Subject: Honestly, it depends on your account....
If it is strictly verbatim, then yes.
Depends on the account contract. The TAT for sm
Subject: Depends on the account contract. The TAT for sm
the company will be longer than the TAT for the MT. In other words, the company may have 24 hours to get the report turned around, but when they give it to the MT, the MT may only have 2 hours. I've been accustomed to a 2-hour TAT with the nationals I've worked for.
Again depends on account; don't think MQ ever uses the symbol. nm
Subject: Again depends on account; don't think MQ ever uses the symbol. nm
nm.
I guess it depends on your account. sm
Subject: I guess it depends on your account. sm
I have always typed it RBCs per high-power field.
In verbatim account... HELP PLEASE
She is sating(satting) 98% on room air?
I want to change, but on verbatim, I suppose I'm not supposed to, right? I'm relatively new to this and not sure.
Verbatim account
Subject: Verbatim account
How would you type... as I have it?
ESL help..with verbatim account..
Subject: ESL help..with verbatim account..
would you type re-meet? remeet? or change to meet again... It is vebatim, but I'm not used to that yet... need seasoned advice! Thanks!
On a verbatim account, would you
Subject: On a verbatim account, would you
actually leave this sentence as is?
She puts Neosporin on it, and she reports that in the morning it looks pussy.
TIA for any input.
Only if the account is verbatim would I
Subject: Only if the account is verbatim would I
type 5 foot. Should be 5 feet.
It is a verbatim account so I can't add the bag ;) sm
Subject: It is a verbatim account so I can't add the bag ;) sm
He just said the patient was *ambued and could not be intibated due to facial trauma*
So, looks like this is one of those that is up in the air and probably something to talk to company QA about?
Is this a verbatim account?
Subject: Is this a verbatim account?
If not, it would make more sense like this:
It would help beneficial organisms AND commensals bacteria colonize his colon and help as a first line of protection against disease.
If not, then I would type:
It would help beneficial organisms, commensals bacteria colonozie his colon and help as a first line of protection against disease.
Since they want the beneficial bacteria and commensals bacteria to colonize his colon, there is no need for a comma before colonize.
If the account is verbatim, I would say OK
Subject: If the account is verbatim, I would say OK
I use it only if my account is verbatim.
Subject: I use it only if my account is verbatim.
If you are on a verbatim account it could be 4, 80 and 0.
Subject: If you are on a verbatim account it could be 4, 80 and 0.
Verbatim account?
Subject: Verbatim account?
Valsalva maneuver. Lots of docs turn it into a verb, so I would say if it is verbatim, what you have is how to spell it, all lower case.
Unless its a verbatim account
Subject: Unless its a verbatim account
I rearrange the sentence so that it is not the beginning. If it is a verbatim account you don't want to change anything but type as both letters in caps, PH.
if verbatim account yes sm
Subject: if verbatim account yes sm
It depends on the client profile. On my non-verbatim accounts, I leave out the is and are in the vitals signs and for allergies, I just type the Demerol and Penicillin under the heading. That's just how I've been doing it for over 15 years and so far so good :)
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